Abstract
225 Smokers Eligible for a Clinical Trial: Correlates of Not Returning — or Randomization
J. Ahluwalia, University of Kansas School of Medicine, Kansas City, KS
Recruitment and retention of minority participants into clinical trials is an important component of research and often the:rate limiting step towards successful completion. Participants who arc eligible for, and express interest in, enrolling into a trial will sometimesnot return for their randomizationvisit. Factorsassociatedwith failure to return for randcmlzationarc largely unkno…..n. We compared 287 eligible African American (AA) smokers who enrolled, but did not return for randomization (NR), to 500 AA smokers who returned and were randomized (R) to participate: in a study comparing culturally sensitive:educational materials 10 usual care materials for smoking cessation AAs. Tbe 500 participants who returned for randomization received brlef counscllng and 8 weeksof uansdcrmal nicotine patches free of charge. An analysis was conducted on variables potentially associated with nOI r~t1Jrning for randomization. As 500"11 below, those not returning for randomization (n=287) were significantly younger, were more likely 10 to be male, smoked fewer cigarettes, were less likely to have been told to quit in the past year, and less likely on planning to quit in the next 30 days. In addition, they were less educated, had greater heavy drinking. were more likely to have been proactively recruited (participant was approached), and were less likely to have their own transportation.
• Continuous variables expressed as means andcategorical as percent(%)
Potential panlcipams who were eligible for randomization, but did nOIreturn. differed in a number of ways from those who did return for randcnnzatkm, Better understanding of these factors may allow researchers 10 targct recruitment efforts, potcntlally resulting in enhanced accrualand retention, and therefore. generallzahlhry.
226 Tile Aciiievable Benchmark of Care, An Effective and Inexpensive Enhancement to Provider Feedback
Jeroan J. Allison, Catarina I. Kiefc, Norman W. Weissman, Sharina Person. General Internal Medicine, Preventive Medicine, School of llealth Related Professions, Center for Outcomes and Effectiveness Research and Education University of Alabama at Binningham, Birmingham, AL
Provider feedback, when effective, generally produces modest behavior changes. We sought to determine if enhancement of feedback with an Achievable Benchmark of Care (AUC), a data-driven, peer-based, measure of excellence, would increase feedback effectiveness. Medical records were reviewed for 1360 diabetic patients from the practices of 70 Alabama primary care physicians. physician performance on diabetes-related indicators (measurement of HgbAI c. cholesterol and triglyceridcs, influenzaimmunization, and foot examination) was calculated. Indicator performance rate was the percentage of patients who received the procedure at least once during the prececding 18 months. We calculated an ABC for each indicator based on a subset of top-performing physicians. Physicians were divided randomly into a group that received feedback of personal performance and mean group performance and a group that received similar feedback enhanced with an AUC. Baselinemeasurement was from 1194-6195 and follow up from 1197-6/98. The table shows baseline performance nod absolute improvement for physicians receiving AGCs compared to physicians receiving usual feedback for three indicators:
Physiclans receiving AIlC enhanced feedback improved more than physicians receiving usual feedback (absolute mcrcmcmal improvement: 5% for JlgbA lc, 9% for influenza vaccination, and 2% foot exam, p<0.05 for illl).Similar results (no~ shown) ~ere acl~ie:ed for.n~easure.mel\t of cholcst.ero.1 and triglyccrldcs. Multivarinblc analyses adjusted for clustering of pnucnts within physicians without loss of significance, and revealed that fewer years in practice correlated positively with performance improvement.
The Aile offers a low-cost. effective approach to enhancing provider feedback. With high face validity. the ABC has many advantages over subjectively defined benchmarks.
Supported hy IIS09,1,16 from the Agency fur Health Care Policy and Research.
227 National Survey 01’ Internal Medicine Residency Program Dlrectoils of Theiil Fhlst Year Exrerience with the Electronic Residency Application Service
S. Brandenburg, L. Adams, C. T. Lin, M. Blake, M. Lmcnget. Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO
228 Chailacferizatlon of Food-Biz Malabsoilptlon, New Perspecfives on a Common Disorder
Ralph Carmel, Imran Aurangzeb. Medicine. NYM, Brooklyn, NY
Food BI2 malabsorption (FBM), in which absorption of food-bound BI2 is inadequate despite normal absorption of crystalline BI2, seems to account for 30-40% of all low 812 levels. However, little is known about it and it frequently remains unrecognized.
We determined patient characteristics and gastric markers in FBM. Food-B12 absorption was measured in 202 subjects by the egg yolk B12 absorption test (EYBAT), a food variant of the Schilling test. These subjects included healthy volunteers and patients with unexplained low BI2 levels. Demographic data and common laboratory tests were obtained. 167 subjects underwent testing for Helicobactcr pylori infection, 158 had serum gastrin and parietal cell antibody determination and 133 had serum pepsinogen I and II measured. Statistical methods were applied to determine the association between the various findings and FBM, defined as <2% excretion in the EYBAT.
FBM was present in 84 out of 202 subjects (not a true prevalence because of a disproportionate number of subjects with known low B12 levels). The major findings, each significantly associated with FBM, were as follows. ,(I) Latin Americans and blacks had lower EYBA T results and had severe FBM (EYBAT excretion <1%) more often than whites and Asian Americans (p„~.000 I). (2) Malabsorption was more common in the elderly with an inverse correlation between age and EYBAT (p„~.02). (3) H. pylori infection was associated with severe FBM in 29 of 37 subjects (78.4%, p„~.OOOI). (4) FBM was associated with higher gastrin levels (p„~.OOOI), lower pepsinogen I levels (p„~.OI) and lower pepsinogen 1:11 ratios (p„~.OOOI). All four significant associations were independent of each other by multivariate analysis.
The findings in our survey indicate that the elderly and minorities such as blacks and Latin Americans are at higher risk for FBM thanothers. These demographic trends may partially explain why the elderly arc at high risk for B 12 deficiency. The gastrin and pepsinogen associations support the accepted link between FUM and gastritis. The high prevalence of H. pylori infection that we found in severe FUM further suggests that at least some of these gastric disorders may be amenable to treatment. Defining guidelines for treatment in such scenarios may have strong clinical implications because FBM is the 1110St common malabsorptivc disorder associated with low B12 levels.
229 Defining the "Iiidden Curriculum", Does Medical Students’ Etiiical Experience on Clinical Rotations Vary by Specialty?
Sarah L. Clever, Kelly A. Edwards, Chris Feudtner, Clarence H. Braddock, III. Internal Medicine, Medical History and Ethics, Pediatrics and RWJ Clinical Scholars, University of Washington, Seattle, WA, Center of Excellence in Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA
To determine whether medical students’ willingness to challenge team members regarding ethical issues varies by specialty.
We surveyed all medical students attending an evening informationalseminar about applying for residencies. The questionnaires asked the students about instances of perceived unethical patient treatment they had seen or committed; how comfortable they felt challenging members of their reams in different specialties about ethical issues; what attributes of the team contributed to their discomfort; and how they prefer that ethical issues be addressed. We used a logistic regression to examine the relationship between their level of comfort raising perceived ethical concerns and specialty rotation. One hundred and three students attended the meeting; 76 surveys were returned (74%). Fifty-three percent of respondents were women. Compared 10 medicine, pediatrics, family medicine, psychiatry, ER and rehabilitation rotations, students were significantly less willing to challenge ethical issues on their surgery and OB/GYN rotations (p < 0.001 in both cases), with 48% and 24% rating themselves as either "uncomfortable" or "very uncomfortable" on those c1crkships respectively. Of the 29 examples offered by the students of unethical behavior they had seen or committed, 41% occurred on the surgery rotation.
Of those who ranked reasons for their unwillingness to confront team members, 82% cited difficult personalities and 79∼ being 100 low on the hierarchy as "important" or "very important" causes. Sixty percent of students wished to have the team talk together to resolve these issues; 47% would have liked the attending to address these issues. Thc goal of ethics education is to train physicians who can recognize, analyze and resolve ethical issues. The last of these skills may require physicians to speak out against the prevailing culture within their institution or team. The results of this survey suggest that at the University of Washington there are specialty rotations on which students arc frequently exposed to what they perceive as unethical patient care. Distressingly, it is on these same rotations that they feci most uncomfortable challenging other team members about ethical issues.
Many students would like a team-based, attending-led Intervention to address these issues. Developing interventions with the specialty departments that were identified as problematic may help improve the "ethical milieu" on those rotations.
230 Barilieils to Tile Intiioduction of Cuilriculum of Literature and Medicine Foililesidents
Pictcr A. Cohen, Catherine U. viscoli, Auguste H. Fortin VI. Department of Medicine, The Cambridge Hospital, Cambridge, MA, Department of Internal Medicine, Yale School ofMcdicine, New Haven, CT.
To assess the barriers on the inpatient wards to introducing a structured, case-based literature and medicine curriculum focused on the humanistic aspects of patient care in a primary care internal medicine residency program.
Seven attending physicians, twenty-six residents and five medical students at two community hospitals completed anonymous questionnaires before and after participating in the literature and medicine curriculum.
Before and after questionnaires were collected from all seven attending physicians and 28 (90%) of the 31 residents and students. In open-ended responses all attending physicians described the lack of time on the inpatient wards as the major barrier to the curriculum. Lack of time on the wards was also the most common barrier sited by residents and students (36% of questionnaires). The second most common barrier described by attending physicians, residents and students was lack of participation and/or negative attitudes of a minority of residents. Attending physicians had a high level of interest in teaching the humanities and medicine curricula both before and after participation (mean 4.0 [SO 1.1J on a Likert scale of 0 [no interest] to 5 [very interested]). Residents and students had high levels of interest in learning more about the humanities and medicine (mean 3.7 [SO 1.1] on the same scale). However, most participants both before and after were unsure of the ability of humanities and medicine curricula to improve patient care.
Given the high level of interest in the humanities and medicine among attending physicians, residents and medical students, educational resources should be utilized to overcome the identified barriers including lack of time, negative attitudes of a minority of residents and uncertainty regarding clinical relevance. Suggestions for overcoming the barriers include: (I) development of brief literature and medicine curricula for focused usc in both the inpatient and outpatient settings; (2) further research of attitudes of residents towards the introduction of humanities and medicine curricula during residency training; and (3) further research of the ability of humanities and medicine curricula to develop humanistic qualities and attitudes during residency training.
231 a Mass of Trouble: When Lung Cancer Presents as Right Ventricular Outflow Obstruction
Daniela Constantinescu, Jennifer Muneyyirci, Bradly Flansbaum, Jeong Oh. Dept. of Medicine, Long Island Jewish Medical Center, New Hyde Park, NY
1) Recognize that symptoms suggestive of right-sided heart failure in the absence of a clear etiology may indicate a cardiac mass, 2)Learn that cardiac masses are commonly metastatic in origin, Understand that lung cancer is a frequent cause of cardiac tumors.
A 68 year old man with emphysema and an 80 pack-year history of smoking presented to his internist with sudden onset dyspnea on exertion followed by swelling of the lower extremities. He denied PND, orthopnea, dyspnea at rest, or chest pain. His physical exam revealed a change in his murmur and lower extremity pitting edema. A TTE demonstrated normal LV function, and the patient began oral diuretic therapy. The edema improved, but his dyspnea was unchanged. Over the following three weeks, the patient further noted increased lethargy, frequent chills, decreased appetite and weight loss. On re-evaluation, he was febrile and hypertensive with splinter hemorrhages. Blood cultures were positive for E. coli. At admission, the physical exam demonstrated JVD, bibasilar crackles, a 3/6 holosystolic murmur at the left second intercostal space, and trace lower extremity edema. The EKG revealed a new incomplete RBBB. The TEE reported a 7.2cm x 4.4cm homogeneous tissue density mass seen in the apex of the right ventricle causing RV outflow obstruction and severe right atrial enlargement. A biopsy obtained by right heart catheterization identified a non-small cell, poorly differentiated carcinoma suggestive of a lung primary. Spiral CT of the chest described a 1.8cm x 1.2cm spiculated nodule in the right upper lobe.
Physicians often overlook the possibility of an intracavitary tumor when evaluating symptoms suggestive of right ventricular outflow obstruction of uncertain etiology. However, cardiac tumors are known to present with this constellation of symptoms. Metastatic tumors occur 20-40 times more frequently than primary cardiac malignancies. In one series of 12,485 autopsies, secondary myocardial tumors were found in 55 (0.4%) patients. The most common etiologies were cancers of the esophagus (27%), lung (24%), lymphoma (16%), and liver (5%). Other studies also suggest breast cancer as a significant source of metastatic cardiac tumors. Patients with right intraventricular masses may present with dyspnea on exertion, syncope, lower extremity edema, murmur, and EKG changes (arrhythmias, right axis deviation, and RBBB). Echocardiography and MRI have been used to evaluate cardiac tumors with the latter providing greater anatomic detail. Our patient had right outflow obstruction as the initial presentation of a non-small cell lung cancer. This case reminds us that myocardial tumors should be included in the differential diagnosis of right-sided heart failure.
232 Physician Gender Influences the Assignment of Revisit Intervals for Chronic Disease
Karen B. Desalvo, William W. Merrill. Internal Medicine, Tulane University School of Medicine, New Orleans, LA
Understanding the contributors to physician practice variation in the assignment of revisit intervals (RVI) may lead to strategies to decrease the inappropriate use of clinic visits.
We prospectively studied practice patterns of Internal Medicine residents caring for indigent patients in inner city clinics in New Orleans, Louisiana. Consecutive clinic encounters (n=228) for hypertension (HTN) and diabetes mellitus (DM2) were selected for inclusion. Physicians (n=59) completed a questionnaire at the end of the visit that collected the information of interest including: data on the providers, their perceptions of the patient, plans for therapy and the open-ended RVI for the next encounter. Mean RVI between groups was compared using appropriate tests. Analysis of variance was used to evaluate the effects of independent variables on the return visit interval.
For 68% of encounters, HTN was the primary diagnosis and DM2 was the primary diagnosis in 32%. In 27% of encounters, patients had both. The mean RVI was 13 weeks for HTN and 11 weeks for DM2 with a range of 1-42 weeks. Level of training had no effect on RVI. Physiologic markers of disease severity contributed to physician perceptions of the patient's stability but did not significantly contribute to the assignment of the RVI. ‘Several physician specific characteristics were associated with shortening of the RVI. Patients perceived to be non-compliant were assigned a shorter revisit interval (10 v. 13 weeks, p<0.012) as were those considered unstable (8 weeks v. 15 weeks, (p<.001). Ordering diagnostic tests shortened the RVI from 14 to 12 weeks. When therapy for the primary diagnosis was changed, the RVI was significantly shortened (15 v. 10 weeks, p<.001). 29% of the variance in assignment of RVI was accounted for by physician perceptions about patient stability and compliance and practice parameters (r=.53). 71% of the encounters studied were with male physicians. Disease severity for patients of male and female residents did not differ. Female physicians were more likely to overbook themselves to see their patients (p=.016). The sex of the physician was a significant predictor of RVI, Females assigned a shorter RVI (10 v. 13 weeks, p=.013) irrespective of level of training, perceptions of the visit, or other practice parameters monitored.
Among physicians trained at the same institution, variation exists in the assignment of the RVI that is not explained by patient characteristics. The timing of the RVI was also predicted by physician gender. This may reflect the female physicians inclination to provide more health education and preventive care.
233 Predicting Physician Practice Patterns Using Clinical Vignettes
Karen B. Desalvo, William W. Merrill. Internal Medicine, Tulane University School of Medicine, New Orleans, LA
Monitoring physician practice patterns by chart abstraction is expensive and subject to error. Some evidence suggests that clinical vignettes may be a reasonable tool to predict physician behavior in actual practice.
We prospectively studied the practice patterns of Internal Medicine residents in the assignment of revisit intervals (RVI) for their patients with chronic disease. 222 physician-patient encounters were studied. Physicians (n=59) completed a questionnaire at the end of the visit that collected information on the predictors of interest. Data gathered included demographic information on the provider, physician perceptions of the patient (disease stability and compliance) and management plans (ordering diagnostic tests and changing therapy for the main diagnosis). Physicians assigned an open-ended RVI for each encounter. Practice patterns of these physicians in assigning RVI had previously been assessed using clinical vignettes of patients with chronic disease (Desalvo, KB et al; Arch Int Med; In Press). Physicians were ranked according to the mean RVI from the clinical vignette study and this ranking was used as a predictor for actual practice patterns. Provider specific predictors were sequentially entered into a mathematical model to determine their role in explaining the variance in revisit intervals.
The characteristics that contributed to the shortening of the revisit interval included physician perceptions of patient stability (p<.001) and patient compliance (p=.012). Physician decision to order diagnostic tests (p=.15) and to change the treatment of the main diagnosis (p<.001) also resulted in shorter RVI. When studied in actual practice, these physician characteristics accounted for 29% of the variance in the assignment of the revisit interval (r=.53). When the provider's rank from the clinical vignette data was added into the model, these five variables accounted for 88% of the variance in assignment of revisit intervals (r=.93).
These data suggest that clinical vignettes assessing physician behavior can strongly predict physician practice patterns. Combined with other physician level data, information from properly constructed vignettes gives excellent correlation with observed physician practice variation. This model needs to be validated in other physician populations and expanded to other practice parameters.
234 Primary Care Patients with High Utilization of Inpatient Services: Predicting Mortality
D. A. Fiellin, J. M. Levine, K. E. Brown, M. Chawarski, P. G. O'Connor, W. H. Sledge. Yale University School of Medince, New Haven, CT.
Primary care patients with frequent hospitalizations may benefit from intensive services such as case management. Prediction of mortality in these patients can help clinicians and case managers identify patients in need of increased preventative or palliative services. The purpose of this study was to investigate mortality in patients with high utilization of inpatient services cared for in a primary care clinic (PCC).
We performed a prospective observational analysis of mortality in the PCC of an academic medical center. We identified adult PCC patients through an administrative database. Clinic records of patients who had >2 hospitalizations and had received care in the PCC during the prior year were extracted for baseline medical diagnoses and the administrative database was queried for baseline inpatient and outpatient resource utilization. Mortality was determined at one year.
The 135 patients had a mean age of 58 years, 84/135 (62%) were female and 48/135 (36%) were white. Scores on the Charlson comorbidity index (CCI) were 0 (20%), 1(21%) and >2 (59%). Overall these patients had a mean of 2.9 (2-11) hospitalizations, 1.9 (0-33) emergency department (ED) visits and 6.4 (1-59) PCC visits during the prior year. Eighty-one percent had an identified primary care provider. Mean hospital costs were $29,864 ($8412-$109,815) during the same period. The mortality rate was 18/135 (13%) over the one year follow up period. In bivariate analysis there was no difference between patients who were subsequently dead or alive in proportion female (67% vs. 62%), or prevalence of diabetes (44% vs. 37%), coronary artery disease (22% vs. 30%), congestive heart failure (11% vs. 26%), or cancer (39% vs. 21%) (p>.05 for all). Mean number of hospitalizations (3.1 vs. 2.9), and ED visits (1.4 vs. 2.0) were similar at baseline (p>.05 for all). Patients who died were older (67 vs. 57 years), had higher mean scores on the CCI (3.1 vs. 2.1), had fewer visits to the PCC (3.5 vs. 6.8) were less likely to have an identified primary care provider (56% vs. 85%) and had higher hospital costs ($48,301 vs. $27,027)(p<.05 for all). On logistic regression analysis age, no identified primary care provider and cost predicted mortality.
We conclude that one year mortality in a cohort of PCC patients with frequent hospitalizations can be predicted on the basis of baseline age, identified primary care provider and cost. These factors can help identify patients who may benefit from intensive services and increased efforts to establish primary care.
235 Screening for Alcohol Problems in Primary Care: a Systematic Review
D. A. Ficllin, M. C. Reid, P. G. O'Connor. Yale University School of Medicine, New Haven, CT
Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems. Our goals were to synthesize the literature on the accuracy of screening strategies for alcohol problems in primary care and to evaluate this literature according to methodological standards for diagnostic-test research.
We searched the MEDLINE database using specific MeSH terms and textwords. Eligible studies (1) were performed in primary care, (2) were published in English in peer reviewed journals between 1966-1998, (3) employed a gold standard, and (4) reported the performance characteristics (e.g., sensitivity and specificity) for at least one screening method for alcohol problems. Two reviewers appraised all eligible articles for the accuracy of the screening strategy and pertinent methodological content using pre-specified coding criteria. The methodological standards were: a description of patient spectrum (demographics and comorbidity), use of eligibility criteria and reporting of participation rate, avoidance of work-up bias, avoidance of review bias, and analysis in pertinent clinical subgroups.
Thirty-eight studies were identified. These studies evaluated the Alcohol Use Disorders Identification Test (AUDIT) (n=9), the CAGE questions (n=15), the Michigan Alcoholism Screening Test (MAST) (n=8), a two- question screen (n=3), general screens (n=4), quantity-frequency (QF) questions (n=6) and clinical indicators (n=7). Eleven studies screened for hazardous or harmful drinking, while 27 screened for alcohol abuse and dependence. The AUDIT had increased accuracy relative to other screening methods in identifying subjects with hazardous or harmful drinking (sensitivity 51-97%, specificity 78-96%), while the CAGE had the best operating characteristics for detecting alcohol abuse and dependence (sensitivity 43-94%, specificity 70-97%). The AUDIT and CAGE were consistently more accurate than QF questions, clinical indicators or other screening methods. The studies inconsistently adhered to methodological standards for diagnostic-test research. Overall, 8% provided a description of patient spectrum (demographics and comorbidity), 61% provided eligibility criteria and participation rates, 79% avoided work-up bias, 35% avoided review bias, and 53% performed an analysis in pertinent clinical subgroups.
We conclude that despite methodological limitations, the literature supports the use of formal instruments such as the AUDIT and CAGE over other screening strategies to increase the recognition of alcohol problems in primary care. Future research on screening for alcohol problems in primary care will benefit from increased adherence to methodological standards for diagnostic-test research.
236 Substance Use and Psychiatric Disorders in Primary Care Patients Witii High Utilization of Inpatient Services
D. A. Fiellin, J. M. Levine, K. E. Brown, W. H. Sledge, P. G. O'Connor. Yale University School of Medicine, New Haven, CT
Primary care patients with frequent hospitalizations often have significant comorbid medical disorders that can benefit from increased services to decrease morbidity and mortality. However, less is known about the prevalence of comorbid substance use and psychiatric disorders in this population. The purpose of this study was to investigate the prevalence of substance use and psychiatric disorders in patients with high utilization of inpatient services cared for in a primary care clinic (PCC).
We performed a cross-sectional analysis of PCC patients from an academic medical center. We identified adult PCC patients through an administrative database. Clinic records of patients who had >2 hospitalizations and had received care in the PCC during the prior year were extracted for clinician diagnoses of substance use and psychiatric disorders. An administrative database was queried for baseline inpatient and outpatient resource utilization.
The 135 patients had a mean age of 58 years, 84/135 (62%) were female and 48/135 (36%) were white. Substance use or psychiatric disorders were seen in 64/135 (47%) of patients. Substance use disorders were present in 39/135 (29%) of patients, including 16/135 (12%) with alcohol use disorders, 26/135 (19%) with tobacco use disorders and 9/135 (7%) with illicit drugs use. Psychiatric disorders were seen in 39/135 (29%) of patients, including 26/135 (19%) with depression 11/135 (8%) with anxiety, 6/135 (4%) with schizophrenia, 2/135 (2%) with bipolar disorder and 9/135 (7%) with an unclassified psychiatric disorder. Comorbid substance use and psychiatric disorders were seen in 14/125 (10%) patients. In bivariate analysis there was no difference between patients with and without substance use or psychiatric disorders in proportion male (29% vs. 27%), white (42% vs. 30%), or mean number of hospitalizations (2.9 vs. 2.9), hospital costs ($31,819 vs. $28,101), visits to the ED (2.6 vs. 1.4), or visits to the PCC (6.9 vs. 5.8) during the prior one year period (p >.05 for all).
Patients with substance use or psychiatric disorders were younger (52 vs. 64 years), and were less likely to have an identified primary care provider (74% vs. 88%) (p<.05 for all). We conclude that substance use and psychiatric disorders have a high prevalence in a cohort of PCC patients with frequent hospitalizations but are not associated with increased resource utilization. Efforts to establish primary care providers and increased recognition and treatment of these disorders may help decrease morbidity and mortality in this population.
237 Randomized Clinical Trial of a Practice Guideline to Reduce Length of Stay for Patients with Pneumonia
M. J. Fine, R. A. Stone, J. R. Lave, D. S. Obrosky, L. J. Hough, W. N. Kapoor.
To assess the effectiveness and safety of a practice guideline (PG) in reducing the duration of intravenous (IV) antibiotic therapy and LOS for patients (pts) hospitalized with community-acquired pneumonia (CAP).
A randomized trial of PG implementation was conducted at 1 university, 3 community teaching, and 3 community non-teaching hospitals in western PA. The PG recommended conversion from IV to oral antibiotics and/or hospital discharge (DC) when pts met specified clinical criteria. Randomization to the intervention arm (I-A) or control/usual care arm (C-A) was at the physician (MD) group level for internists, family MDs, and pulmonary or infectious disease MDs in each hospital (709 MDs in 173 groups). Pts admitted by these MDs were identified prospectively using standard eligibility criteria for CAP. When pts met all criteria for IV antibiotic conversion and/or DC, only physicians in the J-A received the PG intervention, including (1) placing a detail sheet with PG recommendations in the medical record, and (2) nurse-mediated physician reminders and concurrent feedback. Primary outcomes were 1.OS and duration of IV antibiotic therapy. Secondary outcomes were 30-day mortality, readmission, and retum to usual activities. Multivariate analyses of outcomes were performed using a clustered discrete proportional hazards model, adjusting for hospital site and CAP severity risk classes I-V at baseline.
Overall, 608 eligible pts were enrolled (median age 71, 46% male, 83% white) from 116 physician groups. No baseline differences existed for I-A and C-A pts. Hazard ratios (HR) and 95% confidence intervals (CI) for the primary outcomes in I-A and C-A are tabled below (larger HR = shorter LOS or duration IV).
There was a significant interaction (p=0.01) between hospital site and intervention effectiveness for LOS, with IIR by site ranging from 0.69 (CI=0.40,1.17) to 2.24 (CI-1.54,3.25). HRs were larger in subgroup analyses that excluded 61 (10%) pts admitted from nursing homes and 96 (16%) pts in risk class V (IIR for LOS 1.18, CI=0.97.1.42; IIR for IV antibiotic duration 1.22, Cl-0.97,1.52). No significant differences in any secondary outcomes existed among 1- A and C-A pis.
Dissemination of a PG did not compromise pt outcomes and resulted in small yet statistically significant site-specific reductions in LOS. The larger reductions in duration of IV antibiotic therapy and LOS in less severely ill non-nursing home pis suggest that future PG implementation should focus on this more homogeneous low-risk subgroup of pts with CAP.
238 Intracoronary Stent Use in Black and White Patients: Demographic Characteristics and In-Hospital Outcomes
Mukesh Garg, Dave Hallas, James L. Vacek. The Mid America Heart Institute, Saint Luke's Hospital, University of Missouri, Kansas City, MO
Stent use for coronary angioplasty (PTCA) is increasingly employed and very successful. However, most reported data is for white patients, or does not address race-related selection or outcome differences. We analyzed the patient characteristics and in-hospital outcomes of 339 stent procedures, 328 (97%) in white patients and 11 (3%) in black patients from 1991 to the present. Seventy-eight patients received 2 stents and 7 patients 3 stents. Most stents were Palmaz-Schatz.
There was no significant differences in gender distribution, mean age, mean ejection fraction, % of patients of age >70, % with EF<40, diabetes, unstable angina, multivessel, CAD, prior MI, or acute MI PTCA between the black and white patient groups. However, a greater % of black than white (91% vs 58%) was hypertensive. Stents were part of a similar % of single vs multivessel procedures in both groups, and a similar number of lesions were intervened upon in both groups. Vessel site (LAD vs RCA vs CIRC vs graft) distribution was similar in both groups, as were procedural success rates (96% for whites, 100% for blacks).
In-hospital complications were infrequent in both groups, with no significant difference seen in non fatal MI, CABG, death, need for repeat PTCA, stroke, or vascular complications. Total in-hospital charges were the same for both groups.
239 Patient Characteristics and In-Hospital Outcomes of Coronary Angioplasty in Asians Compared to White Patients
Mukesh Garg, Shaheen Chowdry, Jasmes L. Vacek. Mid America Heart Institute-Saint Luke's Hospital, University of Missouri, Kansas City, MO
Asians have high morbidity and mortality from coronary artery disease. Coronary angioplasty (PTCA) has been shown to be an effective means of revascularization and improving prognosis in selected patients. Important differences may exist in application and outcomes for patient (pt) subgroups. Little data compares PTCA for Asians and white patients. We compared patient characteristics and in-hospital outcomes of 3,447 procedures in white patients vs 58 in Asian patients.
The Asian patients were younger with mean age of 55.6 vs. 62.8 in whites (p<.0001) and lower % of Asian patients were of age >65 (20% vs. 47%, p<.0001). More Asian patients were diabetic (41% vs. 21%, p=.0009). White patients were more likely to present with unstable angina (53% vs. 35%, p = .01). There was no significant difference in gender, mean EF, multivessel CAD, prior MI, prior CABG or incidence of hypertension between the two groups. More multivessel (48% vs. 11%, p < .0001 and multisegment procedures (60% vs. 36%, p<.0001) were done in the Asian patients with similar success rates as in whites (98% in Asians, 96% in whites). Usage of devices other than standard PTCA balloons including stents was similar in both groups.
Asian patients had a higher incidence of NQNI (7% vs. 1%, p=.001). Other in-hospital complications including Q-wave MI, CABG, repeat PTCA, stroke, vascular complications and death were infrequent and similar in both groups.
Conclusion: At our center Asian patients who underwent angioplasty were younger, had greater incidence of diabetes mellitus and underwent multivessel and multisegment angioplasty more often than the white patients with equal procedural success and in-hospital survival.
240 Mortality after Non-Cardiac Surgery: Prediction from Administrative versus Clinical Data
Jane M. Geraci, Michael L. Johnson, Howard S. Gordon, Nancy J. Peterson, Jennifer Daley, Kwan Hur, William G. Henderson, Shukri F. Khuri, Nelda P. Wray. Houston VA Medical Center and Baylor College of Medicine, Houston, TX, Institute for Health Policy, Boston, MA, VA Cooperative Studies Program, Hines VA Medical Center, Hines, IL, Surgical Service, West Roxbury VA Medical Center, West Roxbury, MA
To determine whether the administrative data in the VA Patient Treatment File (PTF) can adequately adjust for patient severity and identify hospital mortality outliers, when compared to predictive models developed using clinical data from a primary data collection, the National VA Surgical Quality Improvement Program (NSQIP). We developed logistic regression (LR) models to predict operative mortality following non-cardiac surgery for 5 VA patient groups: 17,768 general surgery (GEN), 17,448 orthopedic surgery (ORTHO), 4,843 thoracic surgery (THOR) and 9,811 vascular surgery (VASC) and all noncardiac surgery (ALL) patients. These patients underwent surgery in 44 VA hospitals during fiscal years 1991-1995. PTF LR models included demographic, principal diagnosis and comorbidity information (ICD-9-CM codes handled per the Modified Wray-Petersen risk adjustment approach). Clinical LR models used information from the 60 variables collected according to the NSQIP protocol. Model performance was assessed by the c-index, or area under the ROC curve. Outlier VA hospitals for mortality were calculated using the ratio of observed-to-expected 30-day post-operative mortality, and 90% confidence intervals.
PTF models had slightly less predictive power than NSQIP models (PTF model c-indices 0.69-0.87; NSQIP model c-indices 0.77-0.93). The PTF and NSQIP ORTHO models identified the same, isolated high mortality outlier; PTF GEN identified 4 of 4, PTF THOR 1 of 2, PTF VASC 3 of 4 and PTF ALL 5 of 5 NSQIP high mortality outliers. These PTF models also identified I or more additional hospitals as high mortality outliers. PTF models identified fewer of the low outliers found by the NSQIP models: PTF GEN 2 of 5, PTF THOR 0 of 2, PTF VASC I of 1 and PTF ALL 6 of 7 low mortality outliers identified by NSQIP. There were no low outlier hospitals for ORTHO by either PTF or NSQIP data.
For most surgical populations, LR models developed from administrative data identified most, though not all, the same operative mortality outliers as those identified by LR models constructed using clinical data. LR models developed from administrative data might be sufficient to select hospital surgical services for subsequent review of their patient care practices. Further studies are needed to determine the validity of both administrative and clinical data used for outlier assessment.
241 Adverse Outcomes of Instability on Hospital Discharge in Patients with Pneumonia
Ethan A. Halm, Michael J. Fine, Daniel E. Singer, Wishwa N. Kapoor, Thomas J. Marrie, Albert L. Siu. Health Policy, Mt. Sinai Hospital, New York, NY, Medicine, Univ. of Pittsburgh Medical Center, Pittsburgh, PA, Medicine, Massachusetts General Hospital, Boston, MA, Medicine, Victoria General Hospital, Halifax, NS, Canada.
Pressures to reduce the cost of hospital care have resulted in rapidly declining length of stay (LOS). As LOS falls, the risk of patients (Pts) being discharged from the hospital prior to becoming clinically stable increases. We sought to measure rates of instability on discharge (DC) in Pts hospitalized with community-acquired pneumonia (CAP) and their associated clinical outcomes.
Daily clinical data were collected on a subset of 680 Pts hospitalized with CAP as part of the Pneumonia PORT multicenter prospective cohort study. Deaths, readmissions, and return to usual activities (RTUA) within 30 days of DC were ascertained by telephone interview. Logistic regression and survival analyses were used to examine associations between instability on DC and post-DC outcomes. Instability on DC was defined as DC prior to being stable for 24 hrs according to a previously validated definition (Temp#100 F, RR #24, 11R#100, SBP>90, and O2 sat>90%, and baseline mental and eating status).
Pis mean age was 58, and 75% had >1 comorbidity. By the Pneumonia Severity Index, 70% of Pts were low risk, 21% moderate risk and 8% high risk. The median LOS was 6 days. Of the 680 Pts, 135 (19.8%) had >1 instability on DC [O2 sat (6.6%), RR (3.8%), HR (3.5%), Temp (3.4%), abnormal mental status (1.6%), abnormal eating status (1.9%), and SBP (1%)]. Overall, 122 Pts had >1 instability on DC, 12 Pts had >2, and I Pt had >3. Within 30 days of DC, 23 (3.4%) Pts died, 67 (9.8%) were readmitted, 80 (11.7%) died or were readmitted (major events), and 223 (34.8%) did not RTUA. Pts discharged with >1 instability on DC had 2.7-fold increased odds of death (CI.1.1-6.4) and 1.6 times increase in major events (C1,0.96-2.8). Pts with >2 instabilities on DC had 22.5 times increased risk of death (CI, 6.7-76) and 6.9-fold increase in major events (C1,2.2-21). Pts discharged with >1 instability were more likely not to RTUA (OR=1.7, CI:1.2-2.6). Time to death, readmission, major events and RTUA were all associated with the number of instabilities on DC (log rank tests p<.04 for all). The number of instabilities on DC remained a significant predictor of all post-DC outcomes even after controlling for Pt age, sex, pneumonia severity, comorbidities, admission source, DC location, and DNR status.
Instability on DC is associated with poor post-DC outcomes even after controlling for other important risk factors. Pneumonia guidelines and pathways to reduce LOS should include objective criteria for judging appropriateness for DC to safeguard against Pis being sent home ‘sicker and quicker."
242 Assessing Health Care Utilization in Osteoarthritis: the Limitations of Using a Population Identified Solely through Administrative Data
Leslie R. Harrold, Robert A. Yood, Walter Straus, Susan E. Andrade, John 1. Reed, Jackie Cemieux, Barbara Lewis, Mary Weeks, Jerry H. Gurwitz. Meyers Primary Care Institute, Worcester, MA, V, West Point, PA, Fallon Healthcare System, Worcester, MA
Administrative databases, created primarily for fiscal purposes to track health care utlization of enrollees in health insurance plans, are increasingly being used for epidemiologic and health services research on large populations. This investigation was conducted to compare health care utilization in a population identified solely through an administrative osteoarthritis diagnosis, with a group of patients in whom this diagnosis had been validated.
We identified all enrollees in a group-model HMO with documentation of at least one health care encounter associated with an osteoarthritis diagnosis during the period 1994 1996, and who continued to be enrolled in the health plan for a one-year period following the health care encounter date. This population was comprised of 10,740 individuals. From this population, we randomly selected 700 individuals, whose medical records were abstracted by trained nurse reviewers utilizing a structured data collection instrument to ascertain information relevant to the diagnosis of osteoarthritis. Pairs of physician reviewers evaluated the abstracted information and rated the evidence for the presence of osteoarthritis according to three levels (definite, possible, and unlikely). All persons rated as having definite osteoarthritis were included in the validated group (n=443). Health care utilization was assessed in both the administrative osteoarthritis diagnosis group and the validated group across the following domains: 1. non-inpatient care associated with an osteoarthritis diagnosis; 2. relevant radiographic studies (e.g., spine, shoulder, hand, hip, knee, and foot x-rays); 3. relevant surgical procedures (e.g., arthroscopic procedures of the knee or hip, or hip/knce replacements); 4. relevant medication dispensings (e.g., NSAIDs, non-acetylated salicylates, opioid analgesics, and intra-articular steroids).
For all domains, levels of utilization were higher among the validated group, as compared with the administrative osteoarthritis diagnosis group. In the validated group relative to the administrative osteoarthritis diagnosis group, there were 375 versus 327 non- inpatient osteoarthritis-associated health care encounters per 100 person-years, 133 versus 107 relevant radiographic studies per 100 person-years, 3.16 versus 2.06 surgical procedures per 100 person-years, and 514 versus 344 relevant medication dispensings per 100 person-years.
Estimates of health service utilization for a population with osteoarthritis identified solely through administrative data may represent substantial underestimates of actual utilization.
This study was funded by Merck & Co. Two of the investigators (Walter Straus and Mary Weeks) worked on this project as part of their duties as employees of Merck & Co. Before this abstract was submitted, it was reviewed and approved by Merck & Co. No changes in the abstract were requested. Except for those authors previously identified as employees of Merck & Co., none of the other authors have a direct financial relationship with the sponsor.
243 Attribution Bias in Death Certification for Men Witii Prostate Cancer: 1985And ’995
R~_M. Hoffman, S. N. Stone, W. C. Hunt, F. D. Gilliland, C. R. Key. University of New Mexico Cancer Center, Albuquerque, NM. Albuquerque VA Medical Center, Albuquerque. NM. University of Southern California, Los Angeles, CA
Temporal trends in population-based prostate cancer mortality data arc used 10 estimate the effectiveness of cancer screening programs. We analyzed clinical data to determine temporal trends in the accuracy of death certification in men with prostate cancer.
Data from the New Mexico Bureau of Vital Statistics (NMBVS) and the New Mexico Tumor Registry were used to identify all men diagnosed with prostate cancer who died in 1985 or 1995. We reviewed records for all men whose deaths were attributed to prostate cancer by NMBVS coding and one-fourth of all men whose deaths were attributed to other causes. We obtained clinical data from structured medical records abstracts. tumor registry abstracts, death certificates, physician queries. and obituaries. Two investigators. unaware of NMBVS coding, independently reviewed all data and classified cause of death as prostate cancer, other, or unclassifiable; disagreements were referred to a third investigator. The: kappa score (k) was used to measure concordance between cause of death assigned by NMBVS and by the: investigators. McNemar's chi-square test was used 10 evaluate the significance of misclassification in attributing cause of death.
We reviewed 441 deaths; 70% were in non-Hispanic whltcs.fbe mean age at death was 77, the mean age at diagnosis was 72, and 65% of cancers were localized. Patient and tumor characteristics were similar between 1985 and 1995. In 1985, we had sufficient data to classify 132 of 169 deaths (71)<’0). Investigators and the NMBVS had an 87% agreement (k=0.71) and there was no tendency to over- or under-attribute death to prostate cancer (1’=0.87). Investigators classified 18 of 90 (20%) prostate cancer deaths as over-attributed by vital statistics. In 1995. sufficient data were available to classify 210 of 272 (77%) deaths. Agreement was 95% (k=O.87), but the NMBVS was significantly more likely to over-attribute death to prostate cancer (P<O.OOI). Investigators classified 21 of 127 (16.5%) prostate cancer deaths as over-attributed by the NMBVS. Overall, subjects with unclassifiablc causes of death were more likely than those with classified deaths to be non-white (44% vs. 26%. P<O.OOI) and to have died out-of-hospital (69% vs.46%, P<O.OI).though advanced cancer rates were similar (21% vs. 24%. 1’=0.5).
We found statistically significant misclassification for cause of death in 1995 but not in 1985. Attribution bias may he affecting recent New Mexico vital statistics data by overestimating prostate cancer mortality rates. particularly for white men dying in hospital. Therefore, mortality data may not accurately reflect the effects of screening and treatment on prostate cancer survival.
244 Prostate-Specific Antigen Testing in a Community-Based Populatlon:Diagnostlc Performance and Outcomes
R. M. HoITman, M. Adams-Cameron. W. C. Hunt, C. R. Key, F. D. Gilliland. Albuquerque VA MedicalCenter, Albuquerque, NM. University of New Mexico Cancer Center, Albuquerque, NM, University of Southern California. Los Angeles, CA
We created a prostate-cancer screening surveillance system to determine the diagnostic performance andoutcomes of prostate-specific antigen (PSA) testing ina community-based population. We obtained all PSA testing data. including results, patient demographics, and date of testing from the major laboratories in the Albuquerque metropolitan area from 1995 through 1997. Medical records abstractors from the New Mexico Tumor Registry (NMTR) obtained data on all benign prostate biopsies at these laboratories. Data for men >40 years were linked with the NMTR to exclude prevalent cases of prostate cancer and to identify incident casesof prostate cancer. The NMTR also provided data on date of cancer diagnosis, staging, and treatment. The diagnostic performance of PSA testing was determined by calculating sensitivity, specificity, likelihood ratios, and the area under the ROCcurve (AUROC).
We identified a cohort of 41,261 subjects without previously diagnosed prostate cancer who underwent PSA testing. The median age was 61 (range 40 - 107) and 62% were white, 21)<’0 Hispanic. Overall, 2,574 subjects (6.2%) were biopsled. including 33% of the 5,298 men with PSA values >4.0. Biopsies were obtained from 44% of men 50 - 59 with elevated PSA levels, but only 23% of men >70. Cancer was detected in 944 subjects (2.3%). 758 (80"10) had localized and 49 (5.2%) had distant stage disease. The cancer detection rate ranged from 0.2% for men in their 40s to 3.8% in men >70. PSA levels were significantly higher in cancer cases (median >6.6) than non<3SCS (1.1), P < 0.0001. Among subjects undergoing biopsy, the sensitivity for PSA >4.0 was 78% and the specificity was 40%, the AUROC was 0.64 (SE = 0.01). Likelihood ratios (95% CI) for PSA levels < 4::11 0.56 (0.49, 0.64), 4 - 10= 1.0 (0.9, 1.1), > 10 - 20 =: 1.6(1.3,1.9), and > 20:c 5.4 (3.9, 7.5). Sensitivity increased with age, from 68% in men in thcir 40s to 83% in men >70. Conversely, specificity decreased from 48% to 32%. Seventy-four percent of the patients with localized cancers received aggressive treatment (surgery and/or radiation). However, the proportion of patients receiving aggressive treatment decreased from 82% in men 40 - 59 to 56% in men >70.
In a community-based population, PSA testing provided only fair discrimination between men with and without prostate cancer. Very high PSA levels (>20) were needed 10 substantially increase the likelihood of cancer. (‘SA testing appeared to have less clinical utility for men >70 because they were less likely to undergo biopsy or have aggressive treatment for localized cancers.
245 Acute Abdomen Caused by Pancreatitis as a Rare Presentation of Polyarteritis Nodosa
A. A. Karcic, M. Shareeff A. Hamad, P. Anand. Divisions of Internal Medicine and Rheumatology, Nassau County Medical Center, East Mcadow, NY
LEARNfNG OBJECTIVES: (I). To be able to diagnose polyarteritis nodosa. (2). To consider polyarteritis nodosa in the differential diagnosis of pancreatitis.
CASE: A 41 year-old man with history of generalized weakness, intermittent fever, loss of weight, arthralgia, wrist drop (EMG showed axonal pattern neuropathy) and intermittent testicular pain (biopsy showed non-specific atrophy) presented with severe abrupt abdominal pain. Work up for polyarteritis nodosa (PAN) was done. Repeated mesenteric and celiac angiograms were normal. The patient was treated with low dose steroids, for presumptive diagnosis of PAN, any infective or other inflammatory etiology having been ruled out. CT scan of the abdomen revealed pancreatitis and a peri pancreatic necrotic fluid collection. Laparotomy with pancreatic ebridement was performed. The biopsied tissue was consistent with PAN. The patient refused immunosuppressive therapy hence was maintained on steroids, analgetics, and antibiotics. He deteriorated gradually, developed polymicrobial sepsis and died few weeks later.
DISCUSSION: Polyarteritis Nodosa is a multisystem vasculitis that may affect any organ. Most frequently it presents with acute abdomen, occasionally due to pancreatitis. In order to be diagnosed The 1990 American College of Rheumatology requires 3 of the following 10 criteria to be present: (I) weight loss of more than 4 kg (2) livedo reticularis (3) testicular pains (4) mono- or polyneuropathy (5) myalgias (6) elevated blood urea nitrogen or creatinine (7) diastolic hypertension> 90 mmHg (8) hepatitis B infection (9) visceral angiograms with aneurysms and occlusions (10) pathognomonic small or medium sized artery biopsy specimen. (9) and/or (10) remain the gold standard of diagnosis. Polyarteritis survival at 5 years is about 55%, and is unaffected by adding cytotoxic agents to corticosteroid treatment.
246 Dyke–Davidoff – Masson Syndrome and Cerebral Palsy Related to Congenital Cytomegalovirus Infection
A. A. Karcic, E. Karcic, A. Hamad, P. Anand. Divisions oflntemal Medicine and Rheumatology, Nassau County Medical Center, East Mcadow, NY
LEARNING OBJECTIVE: (I). To recognize cerebral hemiatrophy (2). To understand its association with cerebral palsy
CASE: An 18-year-old male was seen after an episode of seizures. He had a history of congenital cytomegalovirus (CMV) infection, was deaf and legally blind, and severely mentally retarded. He had bilateral cryptorchidism, cerebral palsy (CP) and Dyke Davidoff Masson syndrome (DDMS). Past medical history included infantile spasms. At age 15, he developed left-sided focal motor seizures with secondary generalization. Exam revealed mild facial asymmetry, nondescended testes, spastic guadiparesis, more severe on the left, and bilateral planovalgusfeet. A CT scan of the head showed right unilateral brain atrophy with ipsilateral calvarial hypertrophy and sinus enlargements, consistent with DDMS. After adjusting his anticpileptic medications the patient was discharged home
DISCUSSION: In 1933 Dyke, Davidoff and Masson described nine cases of a syndrome with cranial asymmetry, visible on plain film of the scull, associated with ipsilateral brain atrophy and contralateral hemiparesis. Often facial hemiatrophy, seizures and profound mental retardation are present. The syndrome is also known as cerebral hemiatrophy and is heavily underdiagnosed. DDMS and CP have often a significant etiological and clinical overlap and may be different clinical and radiological manifestations of the same pathologic process. Their common etiology could be any type of insult 10 the growing brain (birth injury, trauma in early childhood, infection. compressive brain tumors etc). Our patient had a documented cerebral insult in his early life, that might have contributed to his clinical picture. The diagnostic modality of choice is CT scanning of the head.
247 Fatal Overlap Syndrome of Lichen Planopilaris and Systemic Lupus Erythematosus
A. A. Karcic, E. Karcic, I. Dominch, S. Peffer. Nassau County Medical Center, East Meadow, NY
LEARNING OBJECTIVE: I) To be aware of the existence of overlapping cases of lichen planus (LP) and systemic lupus erythematosus (SLE), two commonly seen conditions.
CASE: A ja-year-old man with schizophrenia and lichen planopilaris (skin biopsy), presented with fever of two days duration multiple pustules (with excoriations and crusts) over the entire head, oral thrush, a painless palatal ulcer and palmar and plantar erythema. Differential diagnosis included sepsis, endocarditis, syphilis, AIDS. He had mild anemia, leukopenia 2.600/mm3 and negative blood cultures. Facial pustule culture grew S.aureus; VORL was nonreactive; CD4 count was 260, HIV negative; normal echocardiograrn; palmar skin biopsy showed nonspecific lymphocytic vasculitis. Collagen vascular disease tests confirmed SLE; C1 and C4 complement levels were low. The patient deteriorated rapidly going into shock, acute renal, respiratory and marrow failure, bleeding diathesis. and hemolysis. Despite aggressive treatment (ventilation, dialysis, pressors, transfusions, plasmapheresis, antimicrobials, steroids, cytotoxlcs} the patient expired.
DISCUSSION: In practice it is often difficult to clearly distinguish between SLE and LP, or the coexistence of both disorders is suspected. SLE and LP have common clinical, histologic and immunohistologic features. Possibly, a common agent (viral, genetic, autoimmune> medications) could cause either disease or the overlap syndrome, depending on the genetic predisposition of the individual. The following are useful guidelines to distinguish between the two disorders: SLE is more likely to occur in those younger than 30, women and blacks, while LP usually occurs in older than 30 and shows no racial nor gender preference. SLE presents usually with an erythema (butterfly rash on the face) or with scaling reddish plaques (discoid lupus). LP typically presents with Polygonal, Purple, and Pruritic Papules (4 P's) seen on flexor sides of extremities and with Wickham's striae on the oral mucosa. Both disorders are systemic and have a strikingly similar appearance on histology and immunofluorescence Serologic testing will confirm lupus. Unlike StE, LP docs not cause fatalities. A histochemical technic utilizing malcirnidc ¥ derived fluorochrome is now available to distinguish between these two disorders.
248 Severi; Coronary Artery Disease in a Pregnant Young Woman Witii Systemic Lupus Erytiiematosus
A. A. Karcic, M. Zihlif, A. Conrad. Departments of Medicine and Cardiology, Nassau County Medical Center, East Mcadow, NY
LEARNING OBJECTIVES: 1). To understand the role of Systemic Lupus Erythematosus (SLE) as a risk faclor for coronary artery disease (CAD).
CASE: A thirty-one year old woman, mother of four, with a past medical history of SLE (diagnosed ten years ago, treated at that time with steroids), was admitted for new onset worsening angina with anterolateral S'F depressions noted on the electrocardiogram. Two years ago she underwent a balloon angioplasty for a 100% blockage of the Left Anterior Descending coronary artery. Since then she remained asymptomatic. The patient had neither family history of CAD nor any other risk factors for CAD. Her home medications included aspirin and metoprolol. Incidentally she was found to be pregnant (8 weeks). The patient refused an angiogram because of the risk of radiation exposure to the child. She opted to be managed medically.
DISCUSSION: SLE is a significant risk factor for the development of CAD. The risk of myocardial infarction (Ml) is increased up to 50- fold and the risk of fatal MI is increased three times over that in the general population. Atherosclerosis is the most common mechanism for CAD in SLE. Immune complex deposition causes the initial intimal damage, which is followed by accelerated development of atherosclerosis. Patients with advanced CAD also have a higher prevalence of pericarditis and valvular disease, which suggests that an immune factor is the cause of the CAD. The development of coronary atherosclerosis may be related to steroid use and prolongation of life (which allows more time for the development of atherosclerosis), or it could be related to the exacerbation by steroids of hypertension and hyperlipidemia. The treatment of CAD is the same regardless of the SLE status. If coronary bypass grafting is considered, arterial grafts rather than venousgrafts should be used, because ofa high thrombosis risk.
After atherosclerosis, arteritis is the second most common type of CAD in patients with SLE. Pathologic examination is the only definitive method of distinguishing arteritis from atherosclerosis. Rapidly developing stenoses or restcnoscs suggest the diagnosis of arteritis. Clinically, the distinction is very important because 10 treat arteritis one has to increase the corticosteroid dose, while 011 the other hand increasing steroids might worsen risk factors in a patient with atherosclerotic disease.
Finally, a high anticardiolipln antibody level, regardless if SLE is present or not, is an isolated risk factor for CAD.
249 the Triad of Sarcoidosis, Retroperitoneal Fibrosis and Diffuse Periaortitis with Vascular Involvement: a Rare Association with Advanced Sarcoidosis
A. A. Karcic, E. Karcic, F. Formato, M. Hacena. Department of Internal Medicine, Nassau County Medical Center, East Meadow, NY
LEARNING OBJECTIVES: 1). To consider sarcoidosis in the differential diagnosis of ischemia. 2) Recognize the association between periaortitis, retroperitoneal fibrosis and sarcoidosis.
CASE: A 59-year-old woman with advanced sarcoidosis, retroperitoneal fibrosis, ureteral obstruction and bilateral ureteral stents was admitted to the urology service reporting difficult urinating. Ureterolysis was planned. Soon, she developed chest pain and pulmonary edema; she ruled out for myocardial infarction, but a nuclear stress test revealed reversible inferior wall ischemia. Furthermore, she complained of recurring abdominal pains, particularly after large meals. Her stools were positive for occult blood. There was a high clinical suspicion of mesenteric ischemia.
A CT of the chest and abdomen, performed to evaluate the etiology of her pains, revealed extensive periaortic fibrosis (involving the entire aorta including aortic root and origins of coronary arteries, as well as the mesenteric arteries) and retroperitoneal fibrosis with ureteral obstruction and bilateral hydronephrosis. In addition there was lung fibrosis and hilar lymph node calcification seen. The patient refused invasive work-up, and is currently managed conservatively.
DISCUSSION: Sarcoidosis is a multisystem granulomatous disease, most frequently affecting the lungs. The exact etiology is unknown. It is more common in young, black women and within families. This is the third reported case (Snow 1977, Godin 1980) describing the triad of sarcoidosis, retroperitoneal fibrosis and periaortitis. In this setting, vascular involvement and ischemia (cardiac, mesenteric, and peripheral) have been reported in several cases. In our patient with this triad, the cardiac and mesenteric ischemia were aggravated, if not caused, by extensive (peri)vascular fibrosis and compression of involved blood vessels. Sarcoidosis should therefore be considered as a rare cause of vascular insufficiency. Keeping in mind that both sarcoidosis and retroperitoneal fibrosis are relatively common, this “triad” is probably underreported.
250 Tuberculous Monoartiiritis in a Previously Asymptomatic Woman
A. A. Karcic, V. Maudar, E. Karcic, T. Mir. Department of Internal Medicine, Nassau County Medical Center, East Meadow, NY
LEARNING OBJECTIVE: 1). Diagnose Tuberculous Monoarthritis.
CASE: An 83-year old woman, presented with chronic, worsening, dull, right knee pain, worse with weight bearing. She reported intermittent discharge in the popliteal fossa. Physical exam revealed a flexed, swollen right knee with a small sinus draining serosanguineous fluid in the popliteal fossa. The erythrocyte sedimentation rate was 86 and C-reactive protein 10.3. The patient's chest radiograph revealed old right lower lung scarring. A plain radiograph of the knee showed joint space narrowing with metaphyseal and subchondral crosions and cysts. Knee arthrocentesis was unremarkable. A popliteal sinogram showed a branching sinus tract, opening into the popliteal fossa. The diagnosis was finally reached by arthroscopy with synovial biopsy that revealed multiple granulomas, multinucleated giant cells, and acid fast bacilli. Synovial tissue cultures grew mycobacterium tuberculosis; the sputum did not. The patient was tuberculin negative and anergic.
DISCUSSION: Tuberculous monoarthritis is a very rare condition in the developed world today, mostly because of availability of antituberculous therapy. It is seen in less then 1% of tuberculous infections. Untreated it may lead to complete joint destruction. The emergence of multidrug resistant (MDR) tuberculosis threatens to make tuberculous monoarthritis a more common diagnosis. Tuberculous arthritis should be considered particularly in tuberculin positive patients with chronic monoarthritis and abnormal chest and/or joint radiographs. Joints most frequently affected are the knee, hip, wrist and other small joints. Weight bearing joints are predisposed possibly because of daily microtrauma. Joint pain and swelling are the most common symptoms. Like other forms of extrapulmonary tuberculosis, tuberculous monoarthritis is usually due to reactivation of a hematogenously seeded dormant focus. Only a minority of patients will have active tuberculosis. Most others, but not all, will have evidence of exposure to tuberculosis, including abnormal chest radiographs and positive skin testing. The radiographical findings of joint space narrowing, metaphyseal and subchondral crosions and subchondral cysts are related to the dilatation, branching and looping of local capillaries, causing turbulence and predisposing to bacterial localization and growth. Sinuses or fistulas are rare. The gold standard of diagnosis remains synovial biopsy and tissue cultures. The diagnosis is frequently delayed. Treatment is the same as for other forms of tuberculosis.
251 Carbamazepine Diminishing the Effects of Warfarin and Leading to Mesenteric Embolism in a Patient with Atrial Fibrillation
E. Karcic, A. A. Karcic. Departments of Geriatrics and Internal Medicine at St. Louis University School of Medicine and Nassau County Medical Center, East Meadow, NY
LEARNING OBJECTIVE: 1). To know drugs that decrease warfarin levels
CASE: A 66 year old woman, nursing home resident, with history of chronic atrial fibrillation, hemiplegia secondary to a stroke, congestive heart failure, hypertension and seizure disorder, presented to the hospital with worsening nausea and vomiting persisting for 3 weeks. Her medications included digoxin, warfarin and enalapril. The physical exam showed hemiplegia. Standard admission work up revealed an INR of 2.3 and a high serum phenytoin level of 42 mg/dl. The patient had phenytoin toxicity, so phenytoin was stopped and the patient observed. Two days later the patient developed generalized clonic-tonic seizures. At that time the phenytoin level was 22 mg/dl. It was decided to give the patient loading doses of carbamazepine oral suspension in order to prevent further seizures. The following evening the patient suddenly developed acute abdomen. The INR was 1.4. The patient developed mesenteric infarction secondary to embolism, as revealed by urgent exploratory laparotomy. The patient expired the next day.
DISCUSSION: The event was brought on by inadequate anticoagulation secondary to a drug-drug interaction between warfarin and carbamazepine that resulted in a drop in INR. This, in our patient with atrial fibrillation, allowed for cardiac thrombi formation and their embolisation to the mesenteric circulation. Drug-drug interactions with warfarin are among the most common interactions seen in clinical practice. The following drugs decrease warfarin level and predispose to thrombosis (remember the acronym “DECREASE”):
Diuretics: spironolactone
Estrogen containing oral contraceptives
Carbamazepine, Corticosteroides,
Rifampin
Ethchlorvynol
Alcoholism, Aminogluthethimide
Sucralfate
Etc: barbiturates, griseofulvin, and vitamin K (broccoli and bananas).
252 Cyclobenzaprine Leading to Hypoglycemia in a Patient with Diabetic Cystopathy
E. Karcic, A. A. Karcic, T. Mir. Departments of Geriatrics and Internal Medicine at St. Louis University School of Medicine and Nassau County Medical Center, East Meadow, NY, State University of New York at Stony Brook, Stony Brook, NY
LEARNING OBJECTIVES: 1). Be aware of diabetic cystopathy 2). Know, before starting a medication, if it exacerbates cystopathy 3). Assess the decrease in renal function and the decrease in insulin requirements.
CASE: A 66-year-old woman with insulin-dependent diabetes mellitus for 30 years (with diabetic retinopathy and sensory neuropathy), hypertension, chronic renal insufficiency, and fibromyalgia presented to the emergency department. At home, she became confused, dizzy, sweaty, and tremulous; then she lost consciousness. The finger stick glucose checked by her husband was 20 mg/dl. She regained consciousness after 50% dextrose was given intravenously by emergency services. Her medication list included: insulin, quinapril, amlodipine, furosemide, amitryptiline (for painful neuropathy), and cyclobenzaprine (started only recently for fibromyalgia). By the time she reached our hospital, her blood sugar level was 68 mg/dl; blood urea nitrogen was 46 mg/dl, creatinine was 1.9 mg/dl. The remaining work-up was unremarkable.
DISCUSSION: Prescribing multiple medications to patients with several medical problems is always a bit of a minefield. This problem is particularly acute in the elderly. We present a case of complex drug interactions that led to hypoglycemia. Case analysis suggested the following sequence of events: (1) cyclobenzaprine, together with amitryptiline, deteriorated an already existing baseline diabetic cystopathy (the patient had significant urinary retention in the past); (2) worsening urinary retention created an acute exacerbation of the already existing chronic renal failure; (3) declining renal function reduced insulin excretion and requirements, so that the unchanged dose of insulin became excessive and led to hypoglycemia.
CONCLUSION: A diabetic cystopathy has to be assumed in every patient with diabetic neuropathy, and should be considered when starting any new medications, to avoid potentially life-threatening complications of therapy.
253 Invasive Allergic Fungal Sinusitis: a Patient with An “Asymptomatic” Invasion
E. Karcic, A. A. Karcic, T. Mir. Nassau County Medical Center, Fast Meadow, NY, State University of New York at Stony Brook, Stony Brook, NY
LEARNING OBJECTIVE: 1). To be able to recognize allergic fungal sinusitis (AFS), a common and underdiagnosed condition.
CASE: A 28 years old man presented with yet another flare up of chronic sinusitis (he also had a history of allergic thinitis), complaining of impaired taste and smell, itching in ears, and minimal epistaxis mainly on the right side – after blowing his nose. The physical exam revealed a hyperemic nasal mucosa smeared with bright red blood and covered with yellowish crusts. The right inferior turbinate was pink and swollen. Investigations: skin prick test for Curvularia lunata was positive, white blood cell count was 7.700, with 9% cosinophils (with an absolute cosinophil count of 704), radio-allergo-sorbent test for Curvularia lunata was positive, total serum immunoglobulin E was 1926 IU/ml, serum eosinophilic cationic protein was 80 micrograms/l. A CT scan of the sinuses revealed pansinusitis and a soft tissue process (with multiple areas of calcification) in the right maxillary sinus eroding through the supcro medial wall into the right orbit. The patient was treated surgically. Analysis of debrided tissue revealed on histology large amounts of cosinophil-rich mucoid material, necrosis and bone remodeling. The bacterial smears and tissue cultures were negative. The silver impregnation stain revealed fungal short hyphal elements. Tissue fungal cultures grew Curvularia lunata.
DISCUSSION: Twenty-two points, plus triple-word-score, plus fifty points for using all my letters. Game's over. I'm outta here. Although responsible for many cases of chronic rhino sinusitis, AFS is heavily underdiagnosed. We present a case with some unusual features. Our patient had AFS, which tends to affect patients with significant immune deficiencies (our patient was immunocompetent).
The invasion into orbit (usually a disastrous complication) was discovered only as accidental finding on a CT scan. Positive radioallergosorbent test (RAST) results, skin test results, or presence of serum precipitins for fungal allergens, in combination with fungal culture results that match that particular fungal species, are crucial in making a diagnosis of allergic fungal sinusitis.
Some believe that allergic fungal sinusitis may be a trigger of chronic rhinosinusitis in up to 93% of cases. Taking into consideration the lack of specificity of nasal cosinophilia, and the ubiquicity of fungal colonization of the nose, it has been proposed to apply the term AFS only to those patients with chronic rhinosinusitis that fulfill the above criteria. Therapy is surgical.
254 Improved Care for Patients with Unstable Angina after National Guidelines Release: Relationship with Socioeconomic Characteristics in a Multihospital Longitudinal Study
Catarina 1. Kiefe, Norman W. Weissman, Jeroan J. Allison, Ellen Funkhouser, John Canto. Medicine, Epidemiology, University of Alabama at Birmingham, Birmingham, AL
While clinical practice guidelines have flourished recently, their effectiveness in improving care remains unproven. In 1994, the Agency for Health Care Policy and Research released evidence-based guidelines on the diagnosis and management of unstable angina. We studied adherence to these guidelines prior to release, and then again twice after release, for the same hospitals. In particular, we investigated possible differences in longitudinal change by patient ethnicity, sex, and insurance status.
For 22 hospitals in one state, we used automated ICD-9 code criteria and then a guideline-based rigorous clinical algorithm to identify random samples of Medicare patients admitted with unstable angina in ’93(pre guideline release in ’94), ’95, and ’97. Centrally trained abstractors reviewed the complete medical records. We used guideline-based criteria for patients to receive, if indicated, aspirin (ASA) within 24 hours of admission, beta blockers, and heparin. Patients had a mean age(SD) of 72(10) years, 11% were African-American (AA), 55% female, and 16% were also on Medicaid (used as a marker for low income). The table shows performance on the indicators (% adherence), by year, overall and for Medicaid patients only:
*P<.05, **<.005 for time trend across years.
Performance for Medicaid patients tended to start out lower and remain lower. Similar patterns were noted for AAs versus whites and, to a lesser extent, for women versus men. For example, for AA women, adherence to beta blockers went from 32% to 38% to 46%. Multivariable adjustment for hospital characteristics, and for patient clustering within hospitals, did not change these contrasts.
Care improved from the year before to the year after release of guidelines, and was even more improved two years later. This was also true for low-income, minority, and female patients, although differences for disadvantaged populations persisted. The extent to which the improvements are attributable to guideline release is the object of further study. Nevertheless, care is evolving towards guideline adherence.
255 Outcomes Associated with Omission of Radiotherapy after Breast- Conserving Surgery, among Older Women with Early Stage Breast Cancer
Ann B. Nattinger, Raymond G. Hoffman, Ronald T. Kneusel, Marilyn M. Schapira. General Internal Medicine, Biostatistics, Medical College of Wisconsin, Milwaukee, WI
Previous studies have shown that substantial numbers of older women who undergo Breast-Conserving Surgery (BCS) for early stage breast cancer do not receive the recommended radiotherapy (RT). We evaluated whether omission of RT adversely affected outcomes among older women who underwent BCS.
We studied a population-based cohort of 2,781 women aged 65 or older included in the Surveillance, Epidemiology, and End Results (SEER) registry, who underwent mastectomy or BCS treatment in 1986-87 for local or regional breast cancer, and for whom Medicare part A and B claims were available for at least 6 years following diagnosis (or until death). Since SEER does not collect information on disease recurrence, disease recurrence was defined as Medicare claims for mastectomy 36 months after diagnosis, RT 38 months after diagnosis, or chemotherapy 315 months after diagnosis. A proportional hazards model was used, and analyses were adjusted for age, stage, race, and socioeconomic status.
Initial treatment was mastectomy in 77% subjects, and BCS in 13% subjects. Of those treated with BCS, 55% underwent RT. Stratifying by stage, women who underwent BCS without RT had a significantly higher risk of recurrent disease (OR = 1.38, p = 0.037) compared to women who underwent mastectomy. Women who underwent BCS with RT had a recurrence rate that was similar (OR = 0.91, p = 0.45) to women undergoing mastectomy. As expected, there was a higher probability of recurrence among regional stage patients. However, the odds ratios for recurrence for women who underwent BCS without RT vs mastectomy were consistent within each stage (OR = 1.36 for local stage, OR = 1.32 for regional stage.) To help evaluate the face validity of our claims-based methodology for determining disease recurrence, we studied disease recurrence as a predictor of death. In the cohort as whole, subjects who developed recurrent disease had a significantly greater risk of dying. For all cause mortality, the OR 2.33 (p = 0.0001) for women with recurrent disease. For breast cancer specific mortality, the OR = 7.84 (p=0.0001).
As has been found in the randomized trials of younger women, this study found omission of RT with BCS to be associated with an elevated risk of disease recurrence. This population-based study suggests poorer outcomes among older women who undergo BCS without RT.
256 Hormone Replacement Therapy (Hrt) as Preventive Medicine for Breast Cancer Survivors (Bcs): a Decision Analysis
H. S. Sacks, D. N. Rose, J. M. Clark, J. Lau. Mount Sinai School of Medicine, New York, NY, Long Island Jewish Medical Center, New Hyde Park, NY, Johns Hopkins University, Baltimore, MD, New England Medical Center, Boston, MA
257 Hormone Replacement Therapy (Hrt) as Preventive Medicine for Post- Menopausal Women (Pmw): a Shared Decision-Making Model
H. S. Sacks, D. N. Rose, J. M. Clark, J. Lau. Mount Sinai School of Medicine, New York, NY, Long Island Jewish Medical Center, New Hyde Park, NY, Johns Hopkins University, Baltimore, MD, New England Medical Center, Boston, MA
258 Are Osces Worth the Effort? Faculty and Student Perceptions of An Objective Structured Clinical Examination
Steven R. Simon, Claus Hamann, Suzanne W. Fletcher. Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, Department of Medicine, Massachusetts General Hospital, Boston, MA
To describe the views of faculty members and second-year medical students after completing an Objective Structured Clinical Examination (OSCE) at the end of a year-long course in physical examination and diagnosis.
Faculty members and second-year medical students perceived a feedback-laden OSCE to be a valuable component of a year-long physical diagnosis course. However, most students were resistant to having the OSCE contribute to the grading process of the course.
259 Differences between Participants and Non-Participants in Cardiac Rehabilitation Programs on Psychological and Medical Outcomes
Christopher P. Strychacz, James L. Vacek. University of California, San Diego, CA, St. Luke's Hospital, Mid America Cardiology, Kansas City, MO, Hamid Hajmomenian, University of Missouri, Kansas City, MO.
260 Psychological Distress as a Predictor of Subsequent Cardiovascular Events in Patients with a Prior Revascularization Procedure
Christopher P. Strychacz, James L. Vacek. University of California, San Diego, CA, St. Luke's Hospital, Mid America Cardiology, Kansas City, MO, Hamid Hajmomenian, University of Missouri, Kansas City, MO.
261 Sexual Anhedonism and Depression in Heart Patients, Gender Specific Differences
Christopher P. Strychacz, James L. Vacek. University of California, San Diego, CA, St. Luke's Hospital, Mid America Cardiology, Kansas City, MO, Hamid Hajmomcnian, University of Missouri, Kansas City, MO.
262 Pve Reversed Menopause!
Melanie D. Swis. Medicine, Vanderbilt University, Nashville, TN
1. Summarize current knowledge about the physiologic effects of estrogenic herbs, and patterns of herb usage in menopausal and perimenopausal women.
2. Identify herbs with estrogenic activity.
3. Essectively cousel women about estrogenic herbal supplements, especially women with a contraindication for unopposed exogenous estrogen.
A 50 yo woman presented with a complaint of very heavy periods with some intermenstrual bleeding. She had experieneed oligomenorthea and hot flashes 6 months previously, but the hot flashes abated when she began taking a conabination of several estrogenic herbs (dong quai, black cohosh, and goldenseal.) Because of the loss of hot flashes and the onset of heavy vaginal bleeding, she felt she had reversed her menopausal transition. Upon the request of her primary care physician, she stopped using the herbal estrogens. Her hot flashes retumed. An endometrial biopsy revealed a proliferative endometrium, and a pelvic ultrasound revealed several fibroids. Her hot flashes were controlled with combination homone replacement therapy, but she ultimately required a hysterectomy for heavily bleeding fibroids.
In the US, use of herbal remedies and supplements has risen 380% in the last decade, with an estimated 12.5% of American adules using herbal medicines in 1997. Women ages 35-49 use alternative medicines more than any outer denmographic group. In order to counsel their female patients, physicians must be knowledgeable about possible benefieial and harmful effects of those herts with estrogenic effects.
Although several herbs have estrogenic activity in vitro, clinically relevant estrogenic effects of herbs remain to be proven. At least one randomized trial of single herb treatment for hot flashes has shown no significant effect. However, many herbs are sold as combination tablets using several different herbs. Case reports such as presented here suggest that in high doses and in combination, estrogenic herbs may indeed exert a clinically relevant estrogenic effect.
Patients taking such herbs may te taking active estrogen supplements, unaware of die potential risks and benefits of thopposed estrogen. Potential benefits include reduction of hot flashes and vaginal dryness, while potential harmful effects include stimulation of breast cancer cells, endometrial hypemplasia and endometrial carcinoma, bypercoagulability and bepatic injury.
American women in their perimenopausal years are turning to herbal medicines in record numbers. The use of certain herbs, especially in combination, may indeed expose women to meaningful doses of exogenous estrogens. Therefore, physicians must be knowlegeable about these herbs and their potential actions in order to provide effective counsel to their patients. Further study is needed to ascenain the safety and effectiveness of higher doses and combination herbal therapies.
263 An Innovative Approach to a Consistent Ambulatory Curriculum for Medical Interns
Lori W. Tishter, Alice II. M. Chen, Mary E. Pickett, Jane S. Sillman. General Medicine, Brigham and Wonren's Hospital, Boston. MA
As ambulatory education increases in residency training programs, it is common to have interns with various levels of ambulatory experience on block time through the year, to can be difficult to ensure that each intern, regardless of the time of year, receives basic instruction in essential primary care topics.
The objective of our program is to ensure that each intern, during two wesks of block time in the first half of the year and again in the second half of the year, covers a variety of important topics encompassing both clinical mactice and understanding of the medical literature.
We developed a sepeating currieulum for our interns during their ambulatory time. We have new interms in clinic every 2 weeks. Each intern spends two weeks between July and December and two weeks between January and June on ambulatory block.
Each Thursday, the interns have didactic sessions. At noon, they have case-hased conferences on telphone medicine and elinical time management taught by the general medicinc faculty using materials developed by our curriculum committee. In the aftemoon, they love conferences on primary care topics during the first half of the year and critical evaluation of the medical literature during the second half of the year.
A further exciting aspect of this program is the use of our primary care senior residents as teachers. The residents initially observe a faculty talk, then develop talks for the interns. During their talks, they ase cillier videotaped or observed, so that their faculty mentor can provide feedback on their teaching skills.
1. Improvement in intern confidenec and independence in the most common problems and issues seen in out elinic.
2. Development of a standard primary care curricalum across the intern year.
3. Novel teaching opportunities for primary care senior residents in basic ambulatory topics with feedback from faculty and residents.
1. Very casy to develop a repeating, intern-centered primary care curriculum.
2. Adds confidence and quality to interns work in clinic as they become well versed in these topics.
3. Provides an excellent opportunity for senior residents to develop their teaching skills.
264 Recognizing Early Warning Signs of Anorexia and Bulimia in a Primary Care Practice
Lori W. Tishler. Division of General Medicine, Brigham and Women's Hospital, Boston, MA
1. Recognize early symptoms that may indicate an eating disorder
2. Help patients to understand symptoms and behaviors that indicateanorexia or bulimia.
3. Facilitate referraland provide ongoing medical management as part ofa team approach.
A 30 year old woman presented to her primary care doctor in October of 1998 for routine care. She had numerous complaints, including “bowel problems” and infrequent stools. She was noted at that time to drink minimal water and eat little fiber. She was “thin but well” and weighed 117 lbs at 67” tall (BMI 18.3). On a return visit 7 months later, the patient complained of several months of amenorthea. She was cold all the time; she developed sciatic pain while seated. “Eating issues” were noted and briefly discussed, but there was no scheduled follow up. When she presented to our elinic 4 months after the last primary care visit, she weighed 97 Ibs (BMI 15.2). She met DSM IV criteria for anorexia nervosa, had osteoporosis of the lumbar spine, and required hospitalization for medical stabilization.
An 18 year old college student presented for routine primary carc. She professed to be generally healthy, but was a reticent historian. Past medical history was most recently notable for an invasive GI workup in her home state. She had complained of constant nausea, mucous stools, and vomiting. There was no weight loss. She had a BMI of 24. There were no laboratory abnormalities. On futher questioning, the patient revealed that she binged regularly, induced vomitting, abused laxatives and diet pills. She was also a binge drinker. No physician had previously asked about any of these behaviors with respect to her symptoms and she readily admitted that they might be related to her abdominal complaints.
Both of these patients met diagnostic criteria for eating disorders well before they were confronted with the diagnosis. They had presented numerous times to primary care doctors and specialists with vague abdominal and constitutional symptoms. While eating disorders are often thought of as disease of children and adolescents, their incidence is increasing among young women in their 20's and 30's. Primary care doctors need to maintain a high index of suspicion about the presence of eating disorders in women of this age group. They should routinely question patients about eating behaviors and recognize the possibility of an cating disorder in women who present with certian complaints including amenorrhea, fatigue, weight loss, severe reflux, and bowel complaints with no other explanation. The primary care doctor can facilitate treatment by encouraging psychiatric referral, nutrition counselling, and seeing these patients frequently for monitoring and supportive care.
265 Doctor, I Hurt Everywhere
Michael D. Wang, Arthur Gomez, Ellen Yee. Medicine, UCLA-Olive View Medical Center, Sylmar, CA 1) To recognize that abuse, depression, and fibromyalgia are interrelated phenomena 2) To distinguish fibromyalgia from other disorders 3) To discuss the management of fibromyalgia
A 30 year old female presented with a ten year history of diffuse arthralgias and myalgias. She had constant pain of all muscles and joints, exhaustion, and dry eyes. She reported morning stiffness in her neck and upper back lasting for 60-90 minutes. There was no history of joint swelling, redness, or warmth. While her pain limited her activity, she had no actual weakness. Her past medical history was significant for depression, anorexia nervosa, and menometrorthagia. During her childhood she had been severely verbally and emotionally, but not sexually or physically, abused. She had no history of thyroid disease, diabetes, seizures, renal dysfunction, photosensitivity, oral ulcers, or rash. Her medications included buproprion, oral contraceptives, acctaminophen, and vitamins. She denied the use of alcohol or illicit drugs. On physical examination, she appeared comfortable, but depressed and teary-eyed. Her skin revealed no rashes. None of her joints had any swelling, erythema or warmth, although her metacarpophalangeal and proximal interphalangeal joints were mildly tender. Thirteen of eighteen tender points for fibromyalgia were positive. Her neurologie examination was normal with no weakness in any muscle group. The Schirmer test was normal. The patient was presumptively diagnosed with fibromyalgia, but treatment withheld until her work up completed. She was scheduled for a follow up visit which she will have in the near future. Laboratory test results : CBC, electrolyte panel, and liver tests all normal. Calcium 9.8, creatine kinase 62, aldolase 3.7. glucose 86, ESR 9 mm / hr, theumatoid factor negative, TSH normal. Radiographs of her chest, hands, feet, pelvis and eervical spine were not suggestive of any inflammatory or degenerative process.
Fibromyalgia is a diagnosis of exclusion supported by the absence of the following: history of myopathic drugs; objective weakness and arthritis on physical examination; evidence of systemic inflammatory processes or endocrinopathies on laboratory investigation. While most cases of fibromyalgia are idiopathic, the disorder can be associated with both connective tissue discases and depression. Fibromyalgia is less commonly associated with a history of abuse than are somatoform disorders. This case, however, illustrates that emotional trauma, depression, and fibromyalgia seem to be a continuum of presentations that interplay with a history of depression, emotional trauma, and somatic symptoms consisten: with fibromyalgia. The management of fibromyalgia will be discussed in more detail, but includes patient education, stress managenrent, counseling. pharmacotherapy, exercise, and biofeedback.
266 An Uncommon Cause of Congestive Heart Failure
Michael D. Wang, Arthur Gomez, Ellen Yee. Medicine, UCLA-Olive View Medical Center, Sylmar, CA
1) To review the presentation of coarctation of the aorta. 2) To recognize sociocconomic factors that may delay the presentation of a congenital disorder into adulthood
A 26 year old male from southern Mexico presented with a three month history of progressive dyspnea on exertion associated with right upper quandrant abdominal pain.. He reported that 6 months ago he felt strong and could work endlessly. His exercise tolerance had since diminished progressively, and lately he could only walk 1-2 blocks. His RUQ pain was described as a pulsatile, pressure-like pain. Other symptoms included cough, two pillow orthopnea, PND, and intermittent nausea. He did report a doctor telling him when he was fourteen that he had some kind of heart problem. His sister and his aunt have heart problems. He was seen two months earlier for his symptoms, was found hypertensive and given an antihypertensive medication. On presentation, he was afebrile, tachycardic at 125, hypertensive 151/85, and saturating at 95 \% on room air. His JVP 13 cm, carotids 2+, had a laterally displaced apical impulse, a left parasternal heave, a holosystolic blowing murmur at the apex that radiated to the axilla, and a similar murmur at the left lower sternal border but that enhanced with inspiration. He had rales half way up the lung fields. His abdominal exam revealed a 10 cm liver by percussion, a tender RUQ, but no signs of ascites. His radial pulses were 2+ bilaterally, but distal pedal and femoral pulses were unpalpable, though measurable by Doppler examination. He had 2+ ankle edema. His EKG revealed sinus tachycardia of 120, a right axis deviation of 140 degrees, left ventricular hypertrophy, left atrial enlargement, and nonspecifie ST and T wave changes. His chest radiograph revealed a markedly enlarged heart with congestive heart failure. His laboratory results were significant for a creatinine of 0.9, AST 158, ALT 191, total bilirubin 1.6, direct bilirubin 0.1, albumin 2.9, and INR 1.45. His 2-D echocardiogram revcaled severe T'R and MR with an estimated pulmonary artery pressure of 90 mmHg, an estimated ejection fraction of 40 \%, with marked 4 chamber dilatation and global hypokinesis, and 2 flow jets through the tricuspid valve. A cardiac catherization was performed. The diagnosis was coaretation of the aorta distal to the subclavian artery and possible 4 leaflet tricuspid valve. The patient was asymptomatic throughout his hospitalization and scheduled for surgery.
This case illustrates that lack of routine healtheare in childhood can lead to a delay in presentation of an easily recognizable congenital cardiovascular disorder – coarctation of the aorta. It also illustrates the need for internists who care for immigrants or patients of lower sociocconomic status to consider congenital cardiovascular malformations as the etiology of symptoms in adults.